Anti-D prophylaxis fails for administrative reasons far more often than immunological ones. The commonest are a sensitising event that nobody classified as one, a dose given late, and a woman who received routine antenatal prophylaxis and was then assumed to be covered for the rest of the pregnancy.
Treat all of these as sensitising in a RhD-negative woman with an RhD-positive or unknown fetus: any bleeding after 12 weeks, abdominal trauma including a road accident with no visible bleeding, external cephalic version, amniocentesis or chorionic villus sampling, miscarriage or termination beyond 12 weeks, ectopic pregnancy, and intrauterine death. Give anti-D within 72 hours; if the window has been missed, give it anyway up to ten days, because partial protection is better than none.
Two points that get missed. Routine antenatal prophylaxis at 28 weeks does not cover a later sensitising event — that needs its own dose. And after delivery of an RhD-positive baby, quantify the feto-maternal haemorrhage where the service allows it, because a large bleed needs more than the standard dose and the standard dose will otherwise be recorded as given and assumed adequate.
- Any bleeding after 12 weeks, trauma, version, or invasive procedure is a sensitising event
- Give anti-D within 72 hours; if late, still give it up to ten days
- Routine 28-week prophylaxis does not cover a subsequent sensitising event — give another dose
- Quantify feto-maternal haemorrhage after delivery of an RhD-positive infant where testing is available
- Record the indication, dose and timing; incomplete documentation is how sensitisation happens
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